| NPI | 1366044729 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 333600000X Pharmacy (Licence: VA 0202219139) |
| Additional Taxonomies | 333600000X Pharmacy (Licence: WV RP0012277) |
| Enumeration Date | 2020-11-11 |
| Last Update Date | 2020-11-11 |